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Aortic ulcer intramural hematoma aortic dissection

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Aortic ulcer intramural hematoma aortic dissection

  1. 1. Aortic ulcer – intramural hematoma- aortic dissection: a continuous spectrum R Erbel, H Eggebrecht, D Baumgart, J Debatin J Barkhausen,U Herold, H Jakob Department of Cardiology Radiology and Thoracic and Cardiovascular Surgery University Essen, Germany
  2. 2. Classification of acute aortic syndromes Svensson LG et al.Circulation 99: 1331-6, 2000 1- Classic dissection 2- Intramural hematoma 3- Discrete/subtitle dissection 4- Plaque ulcer, plaque rupture 5- Iatrogenic/traumatic dissection 1 2 3 4 5 ESC TF Eur Heart J 22: 1642 81, 2001
  3. 3. History of IMH • 1920 Krukenberg: Bleeding to the outer layer of the media due to rupture of vasa vasorum without tear. • 1952 Gore, • 1958 Hirst and 1982 Wilson: pathologic studies • 1988 Yamada et al: 1st CT and MRI study • 1991 Zotz et al: 1st IMH FU to AD by TEE • 1994 Mohr-Kahaly: 1st TEE clinical study and FU • 2000 v Kodolitsch et al: „Hemorrhagic stroke of the aortic wall“
  4. 4. Cystic Media Necrosis Collagen Fiber Rupture
  5. 5. Cystic Media Necrosis Collagen Fiber Rupture and Intramural Hemorrhage
  6. 6. Desc. Aorta SAX at 35 cm Intramural Hematoma Typ I N = 17 X = 64 years 3 – 20cm length 0.7 – 3 cm W Th 35% echolucent zones Mohr-Kahaly et al JACC 23:658 – 64, 1994
  7. 7. Intramural Hematoma Type II with Vessel Wall Layering and Shearing N = 10 -Age 70 years -Aortic ectasia,aneurysm -Calcium displacement -3 – 23 cm length -0.7 – 4 cm W Th - 70 % echolucent zones Mohr-Kahaly et al JACC 23:658 – 64, 1994
  8. 8. - Hematoma formation within the aortic wall in the absence of a detectable intimal tear (wall thickening) - Due to spontaneous rupture of vasa vasorum - Potential precursor of overt dissection class 1 - Class 2 aortic dissection Intramural hematoma (IMH) Erbel R, EHJ 2001 Vilacosta, Am Heart J 1997
  9. 9. - Displacement of intimal calcifications - Affects long segment of the aorta Intramural hematoma, Class 2 AD (IMH) Differentiation against thrombosed aneurysm
  10. 10. Meta-Analysis1 (143 patients): - 5-20% of patients with acute aortic syndromes - 61% men, mean age 68 yrs. - 53% hypertension - Rare: traumatic (motor vehicle accident) - 80% chest pain - ~ 21% mortality Intramural hematoma (IMH) 1 Maraj et al,, Am J Cardiol 2000
  11. 11. Outcome1 : IMH- Outcome 1 Mara et al,, Am J Cardiol 2000
  12. 12. Intramural Hematoma Aortography IVUS Class 2 AD type B Intravascular Ultrasound
  13. 13. Pericardial tamponade, progression to dissection, rupture within one week despite RR control IMH- Complications
  14. 14. History of PAU Reports • 1935 Shennan T 4/218 cases AD begin in the base of AU • 1941 Willius /Cragg „some of AD accociated with ulcerating atheromatous abscesses“Vilacosta et al JACC 32:83 – 9,1998
  15. 15. - Elderly, hypertensive patients - Symptomatic vs. asymptomatic (incidental finding) - Most common site: mid/distal descending thoracic aorta - Strong association with concomitant abdominal aneurysm Penetrating Atherosclerotic Ulcer (PAU) Atheroma Plaque erosion Intimal ulcer PAU+IMH Pseudoaneurysm Rupture Von Kodolitsch, Z Kardiol 1998
  16. 16. - Ulceration of aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media - Class 4 aortic dissection - 2.3 - 7.6% in symptomatic patients with acute aortic syndromes Penetrating Atherosclerotic Ulcer (PAU) CTIVUS Erbel R, EHJ 2001
  17. 17. Plaque Rupture class 4 AD Ao Fibrous cap Ulcer core 1 cm Erbel R Heart 2001 IVUS MRI Imaging
  18. 18. PAU- Complications - Intramural hematoma : • 10 – 100% 1,2 •due to erosion of vasa vasorum • upredictor of adverse outcome IMH IMH (Ganaha et a. Circulation 2002) 1. Vilacosta et al JACC 1998 2. Kazerooni et al Radiology 1992
  19. 19. Ruptured Plaque with Floating Fibrous Cap Tear Fibrous Cap Ulcer
  20. 20. PAU- Complications - Pseudoaneurysm : 0- 50%1,2 Growth rate: 0,31 cm/ year 1 Yucel, Radiology 1990 2 Harris, J Vasc Surg 1994 - Embolism: rare
  21. 21. PAU- Complications - 0- 44%1,2 rupture 1 Stanson, Ann Vasc Surg 1986 2 Harris, J Vasc Surg 1994 3 Coady, J Vasc Surg 1998 - 40% for PAU vs. 3.6% for classic type B dissection3 - Risk factors : symptomatic patient, aortic diameter, * type-A PAU
  22. 22. Impending Perforation of Plaque Rupture of descending Aorta Pleura effusion Plaque- rupture Aortic sclerosis class 4 AD
  23. 23. IMH with /without PAU • Age/year 71 67 • Male/% 44 61 • Ao asc/% 9 26 • Ao desc/% 91 74 • WTH mm 16 _ 5 13 _ 4 • Stable 25% 91% • Ao rupture 16% 4% • Ao dissection 12% 4% Pt group IMH with PAU without PAU Ganaha et al Circulation 106:342 – 8, 2002
  24. 24. Indicators of Disease Progression • Age/years 71 72 • Male/% 58 23 • Pain persistence/% 75 7 • Pl effusion /% 75 0 • PAU diameter/mm 21 12 • PAU depth /mm 14 7 • PAU number 1.2 1.5 • Ao diameter/mm 48 46 • WTh /mm 17 14 • IMH segments 3.3 3.9 Clinical Signs Progression Stable Course Ganaha et al Circulation 106:342 – 8, 2002
  25. 25. Media Necrosis Erdheim Gsell Aortic Disease Entry Tear IMH Aortic dissection class 2 AD Aortic rupture Healing No continuity: PAU, IMH, dissection
  26. 26. Arteriosclerosis Progression Stary IV – V Atherom, Fibroatherom Plaque Rupture Ulcer Hematoma Mural Thrombosis VIa VIb VIc Yes: PAU/ IMH/ Aortic Dissection can be a continuity in atherosclerosis
  27. 27. Aortic Diseases Aortic rupture Aortic Disease -congenital -degenerative -arteriosclerotic -inflammatory -traumatc,toxic Healing Trauma Class 5 Plaque rupture Class4 Discrete/subtitle Dissection Class 3 Intramural Haematoma Haemorrhage Class 2 Aortic dissection Class 1 Communicating/no n communicating AD ESC Task Force EHJ 2001
  28. 28. IMHwith PAU MRI: Contained rupture of the descending thoracic aorta due to penetrating (PAU) atherosclerotic ulcer (class IV type B) with IMH
  29. 29. Arteriosclerosis and Aneurysm Formation Preexisting atherosclerosis not required -absence in animals -Proteolytic activity different (MMPs) -Disparity in characteristics of pts Reed et al Circulation 85:205-11,1992
  30. 30. Characteristics of PAU Patients No Sex Age Co morbidity Ao D Location FU 1 F 68 EH 4.4 IIIa IMH,R 2 M 65 EH,CABG 2.9 IIIa free 3 M 66 EH, 2-VD 1.9 IIIb free 4 F 75 EH, CABG 3.0 IIIa IMH,Pseu 5 M 71 EH, 1-VD 3.0 IIIa free 6 M 69 EH,AF 2.9 IIIa free 7 M 78 EH, 3-VD 2.8 IIIa IMH,R 8 M 72 CABG, PVD 3.9 Arch Pseudoan 9 M 72 EH 2.0 II IMH,>1PAU
  31. 31. PAU – Graft Stenting • Stent diameter/mm 34 _ 7 24 – 46 • Stent length /mm 90 _17 60 – 130 • Fluoroscopy time /min 12 _ 6 5 - 21 • Contrast material /ml 244 _ 115 50 - 450 • Neurological deficit none • Late FU 1/9 ex for renal stenosis • Mortality 0 x _ s range
  32. 32. PAU References • Stanson 86 16 81% 44% 44% • Yucel 90 7 100% 14% 43% • Kazeroni 92 16 81% 56% 19% • Harris 94 18 22% - 6% • Coady 98 15 80% 20% 27% • Vilacosta 98 12 100% 17% 42% • Hayoshi 00 12 - - 33% • Quint 01 38 58% 16% - x 134 66% 21% 20% Author year N Sympt Rupture Surgery
  33. 33. PAU References • Stanson 86 16 - - - 44% • Yucel 90 7 - - 0% 0% • Kazeroni 92 16 6% 11% - 31% • Harris 94 18 - 0% 50% - • Coady 98 15 20% 27% - - • Vilacosta 98 12 17% 0% - 0% • Hayoshi 00 12 17% 0% 0% 0% • Quint 01 38 0% 0% 16% 16% Author Year N Mortality Delayed Progress S/stent Rupture to Aneury in FU
  34. 34. Prognosis of PAU Total Type A Type B Aortic dissection 16 % 57 % 12 % Rupture 12 % 57 % 5 % Stable without surgery 54 % 0 % 75 % Mortality surgery 13 % 0 % 13 % med Th 26 % 100 % 11 % total mortality 19 % 57% 14 % v. Kodolitsch et al Z Kardiol 87:917 – 27,1998
  35. 35. Clinical Features of PAU • Age > 65 years sex: M 60% • 15 % Type A, Type B 85 % • RF: EH 85 %, Smoking 72 %, HLP 35 % • 85 % Single PAU, 4 % two, > 2 PAUs 11 % • 73 % IMH • 16 % AD, 4 % typical class 1AD • 27 % Pseudoaneurysm • 19 % Fusiforme Aneurysm • 12% Rupture v. Kodolitsch et al Z Kardiol 87:917 – 27,1998 93 References, nearly all case reports
  36. 36. FOLLOW UP IMH Ascending aorta: n= 3 1surgery 1ruptur 1 dissection Descending aorta: n=24 4 dissection 3 surgery 3 healing 6 death
  37. 37. Assessment of the true and false lumen Ao desc 23 cm 1.19 cm
  38. 38. Visualisation of Intimal Tear using 3D-Echocardiography
  39. 39. Non communicating dissection type B 38 cm Aortic dissection classification
  40. 40. Morphology of False Lumen WL FL WL FL WL FL
  41. 41. Pitfalse Artefacts Explanation: Reverberation of the aortic wall, chest wall Not integrated in the anatomy of the aorta 
  42. 42. Intramural Hematoma class 2 AD Transesophageal Echocardiography Erbel R, Heart 2001
  43. 43. Intramural Hematoma No Intimal flap! circular or half mond- thickening of Aortic wall >7mm Calcification of intima    Mohr - Kahaly et al JACC 1993 class 2 AD Dissection
  44. 44. Drohende Perforation bei Plaqueruptur in der descendierenden Aorta thoracalis Pleura erguß Plaque- rupture Aortensklerose Klasse 4 AD
  45. 45. Case2
  46. 46. Angio-Spiral CT mit KM Aortendissektion Klasse 2 Diagnostik von Aortenerkrankungen
  47. 47. Magnetresonanztomographie Aortendissektion Aneurysma Klasse 1
  48. 48. Aortographie TL FL Aortendissektion Klasse 1 Svensson LG et al. Circulation 1999 Begrenzte Aortendissektion Klasse 3
  49. 49. Intravaskulärer Ultraschall (IVUS) Plaqueruptur (Klasse 4) Plaqueruptur der Aorta Abdominalis (Klasse 4) Intramurales Hämatom (Klasse 2) Eggebrecht H, et al., Heart 2001
  50. 50. Angio-Spiral CT
  51. 51. Case2 • Physical examination: percussion sound dullness over left lower chest and 2/6 systolic murmur heard best over the 2nd intercostal space at the right parasternal line • ECG: Sokolov-index elevated, slight ST-depression V3-V5 • X-ray: Elongation of the ascending aorta and shadowing overleft lowerarea • CK90 U/l; Troponine I 0,1 ng/ml; CRP: 8,4 mg/dl
  52. 52. Case3 • 69 year-old female patient • History : Arterial hypertension >10 y IDDM Atrial fibrillation • Severe thoracic backpain
  53. 53. Case3 • EKG: atrial fibrillation, ST depression II,III • CK33 U/l, Troponine I 0.0 ng/ml
  54. 54. Case3 TEE:
  55. 55. Case3 Intravascularultrasound (IVUS, Manual Pullback) 2DLongitudinal reconstruction Intramural hematoma of the descending aorta (class 2 dissection)
  56. 56. Case3 Antihypertensive treatment: Beta-blocker ACE-inhibitor Diuretics Ca-antagonist RR controlled around 110/80 mmHg After 10 days (just before discharge) : recurrent severe backpain at rest
  57. 57. Case3 Progression to overt dissection
  58. 58. Case3 Progression to overt dissection
  59. 59. Case3 Additional pleural effusion as a sign of impending rupture FL TL
  60. 60. Case3 Therapy: Endovascular stent-graft placement
  61. 61. PAU- Therapeutic approach - Ascending aorta - Descending aorta Surgery Type-A PAU Type-B PAU symptomatic asymptomatic Medical Tx Risk factors: • Aortic diameter • Recurrent pain • IMH • (Pseudoaneurysm) No risk factors Stent-Graft (?)
  62. 62. Diagnostic Aims • Confirmation of diagnosis • Classification, extent • Differentiation TL/FL • Tear localisation (entry , reentry) • Side brnch involvement • Aortic regurgitation (Grading, etiology, valve morphology) • Signs of emergency: periaortic -, mediastinal hematoma, pleural, pericardial effusionOP / Stent - Graft-Stent / medical therapyOP / Stent - Graft-Stent / medical therapy II IIII
  63. 63. IMH- Therapeutic approach - Ascending aorta - Descending aorta Surgery Type-A IMH Type-B IMH No risk factors Medical Tx Risk factors: • Recurrent pain • Progression to dissection • Pleural effusion Stent-Graft (?)
  64. 64. Definition of IMH • Wall thickening < 7 (5) mm • Segmental/crescentic wall thickening • Thrombus – like appearance • Wall layering,layer shifting • Absence of tear(s) and flow • Echolucent zones (+/-),high signal intensity • Central calcium displacement Mohr-Kahaly et al JACC 23:658 – 64, 1994 Mohr-Kahly JACC 37:1611- 13, 2001
  65. 65. TYPE I INTRAMURAL HEMATOMA • smooth luminal surface • circular thickening of the wall • aortic diameter normal (3.5 cm) •irregular luminal surface • extensive arteriosclerotic plaques • ectatic aorta (4,5 cm) TYPE II INTRAMURAL HEMATOMA Mohr-Kahaly et al JACC 23:658 – 64, 1994

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